Regulatory and Accreditation Manager

Mgr Accreditation & Regulatory Job Code: MG1372 ABOUT US

We are welcoming a new era in healthcare where achieving good health is just the beginning. At UVA Health Northern VA & Culpeper, we believe in caring for the whole person by getting to know - and making connections with - our patients. By combining the talent and expertise of our people, the breadth of capabilities across our system, and our commitment to helping our communities get better and stay healthy, we are improving the patient experience.

As a UVA Health Northern VA & Culpeper team member, you will have a voice in patient care decisions, support the most advanced medical technologies and feel a strong sense of satisfaction from making a difference in people's lives every day.

The Manager Accreditation and Regulatory I is a registered nurse or health care professional with a comparable clinical degree who assumes responsibility for managing: (1) Accreditation, certification and regulatory compliance and survey activities in conjunction with the corporate Accreditation and Regulatory team (AR) and the Sr. Director of Accreditation Regulatory through maintaining continuous readiness structures and key relationships with the leaders in the assigned facility(s) and/or corporate functional process.

(2) Processes that assure local, regional/market and corporate standards that dictate care, patient safety and clinical practices as outlined in policies, procedures, forms, and other documents. Each manager position will have individual assignments with facility and/or function-based roles. (1) Facility-based assignment examples:
Ambulatory/Provider-based Practices, Med Quest, Ambulatory Surgical Centers, Acute Care Hospitals. (2) Corporate regulatory function assignment examples:
Policies and Procedures – Corporate, Disease Specific Certification, Corporate Connectivity – Education and Metrics, Clinical Forms – Corporate, All UVA Surgical Services Specialty, All UVA Radiological Services Specialty, All Behavioral Health Emergency Departments Specialty, PJC – Event Regulatory Review Specialty, New Facility Integration – as assigned. Others as assigned.

Education:

4 Year/Bachelor's Degree required - BSN or comparable clinical degree. Graduate Degree preferred.

Experience:

Registered Nurse or Clinical Professional with minimum of 5 years clinical experience required. 2 years of applicable Accreditation and Regulatory experience with 2 years of leadership experience preferred. Refer to the Life Support Training Policy for additional details.

Licensure:
Current RN licensure in applicable state or comparable clinical degree required.

Additional Skills/Requirements

Required:

Excellent verbal communications skills. Displays excellent computer, writing and editing skills. Demonstrates the ability to write clearly and concisely, and in a manner that diminishes risk and provides a clear concise guide for best practices. Ability to work collaboratively with other health care professionals and manufacture change without authority. Ability to organize and determine work priorities and delegate appropriately. Consulting, team-oriented, supportive, and cooperative attitude.

Utilizes appropriate decision-making strategies: authoritative, consultative, consensus. Exhibits self-direction, independent practice, and excellent time management skills. Able to continuously reprioritize, demonstrate flexibility, and process multiple issues simultaneously. Creates an environment that supports and respects diversity, modeling behavior and language that is inclusive, and nurturing an environment where it is acceptable to discuss differences and issues of diversity. Has a questioning attitude.

Additional Skills/Requirements Preferred: N/A

• Analysis:
  Analyzes processes and creates deliverables to provide information and recommendations for improvements.
• Breaks down problems and issues into sub-components and assesses the costs, benefits, and risks of various options.
• Is able to select and recommend the best solution based on a thorough examination of all considerations.
• Is able to explain and justify actions in a systematic and logical fashion.
• Communication:
  Shares and receives information using clear oral, written, and interpersonal communication skills.
• Demonstrates effective written and oral communication skills.
• Actively listens, provides constructive feedback, and demonstrates respect for differing views.
• Tailors communications to diverse audiences.
• Quality Improvement:
  Demonstrates involvement in the unit's annual and/or periodic assessment efforts, including efforts to improve the quality services.
• Understands the value of innovation and quality improvement.
• Improves processes and practices by identifying inefficiencies and redundancies.
• Demonstrates efficiency and quality in one's own work.
• Customer Service:
  Builds relationships and maintains strategic partnerships with key internal and external…